Up on the 4th floor of MLK Community Hospital, it’s nearing 10am. Care manager Mayra Guerrero walks the few steps from the office she shares with her team to the nurses’ station for rounds. After the attending physician, charge nurse, social worker, pharmacist, and bedside nurses have gathered, the chatter dies down, and the work of discussing the day’s patients begins in earnest. Room by room, nurses give their updates to the attending physician, who asks questions, confirms next steps, and agrees with discharge orders.
Though it’s a routine scene at the hospital, the teamwork, experience, and expertise required to ensure that patients not only receive the care they need while at the hospital but are able to continue recuperating afterwards is anything but. And care managers (or case managers—the titles are used interchangeably) are a critical part of the picture.
“It’s such a collaborative thing,” says resident physician Dr. Hsiao-Wei Banks, who has experienced first-hand how important care managers are throughout her three years of training in South LA. What happens inside the hospital, she notes, is often only the beginning of a patient’s care. “In an underserved community, for people without a lot of support, care management becomes crucial to making sure patients can get home and back to their daily lives. [Because] if we haven’t done that, have we really taken care of them?”
A safe discharge from the hospital can be simple: a patient needs a walker, leaves with medication, or has family coming to pick them up. But often, discharges in under-resourced communities like South LA can become battles that pit care managers against insurance representatives, bureaucratic red tape, and the realities of difficult home situations.
Ann Aikens, lead case manager, recalls a patient, Henry*, who was found collapsed outside of a store in South LA and brought to MLKCH. While being treated in the Emergency Department, he suffered from a stroke. In the wake of the stroke, Henry, who was in his late seventies and unhoused, was unable to answer questions about himself. He could not care for himself and had nowhere to go.
Perhaps more so than any other institution, it often falls to hospitals to serve as the final safety net of care for the most vulnerable in society. And the specific details of how that care comes together often falls to care managers.
For more than 40 days, as clinical staff stabilized Henry in the hospital, Ann and her team worked the case. They struggled to find even the most basic information about him and couldn’t find any family to contact. In similar situations, they’ve had to turn to police to try and identify patients through fingerprinting.
But through enough careful digging, Ann and her team were finally able to find an old employer. They called his former boss, who pulled up Henry’s social security number. That was enough to start the process of signing him up for social security, with the hope that a public guardian could be assigned to him and assist with his care. From there, Henry could be moved into a skilled nursing facility and on to the next stage of his life.
Down on the first floor, it’s late afternoon before ICU care manager lead Maya Cox makes it back to her office. Without missing a beat, she pulls up the roster on her computer, checking in on what’s changed with her patients in the last couple of hours.
In the ICU, she sees cases that escalate dramatically, which require the quick thinking of doctors, nurses, and care managers alike. She remembers a woman in her early twenties, Tina*, who’d had a fight with her partner, and in an act of desperation, attempted to overdose on Tylenol. She came in with pain, but when Maya picked up her case, was alert and speaking to her care team. Within hours, however, her condition deteriorated dramatically.
“We knew it was a very precarious situation,” says Maya. “One minute she was talking, the next minute she couldn’t breathe on her own.” Tina was placed on a ventilator, and doctors determined that she would need a liver transplant to survive.
But Tina was uninsured. Because of her insurance status, it would be an uphill battle to have one of the few transplant centers in Los Angeles accept her case. Care managers discussed whether they could get her temporary Medi-Cal. But even then, Maya knew that transplant centers would be concerned about the complexity of the case and—most of all—receiving payment. The chances that her case would be accepted were slim. At a hospital like MLKCH, where most patients rely on public insurance or have no coverage at all, care managers spend much of their time fighting a system not designed to care for the poor.
Meanwhile, Tina’s condition was worsening, and insurance or not, if she did not receive the transplant within the next few days, she likely would not make it. Not everyone might have understood the urgent trajectory of her patient’s liver failure but having worked with liver transplant patients in the past, Maya knew just how little time Tina had.
The usual requests and referrals she put in to have patients transferred would not move quickly enough. She called Dr. Jorge Reyno, Senior VP of Population Health. He reached out to involve the CEO of MLKCH, Dr. Elaine Batchlor.
Late that evening, long after her shift had ended, Maya was still at her desk, staying on her patient’s case.
Her decision to escalate Tina to the highest levels of resources through MLKCH’s CEO was the right call. “Half the battle is utilizing any kind of tools are at your disposal, alongside all of the clinical knowledge you’ve obtained,” says Maya.
Dr. Batchlor reached out to the CEO of a major medical center, who directed his transplant team to accept the case. It was around 7pm by the time they began looking for a bed for Tina. Maya stayed at work until she knew with certainty that her patient had been accepted and she would receive the transplant. Within 48 hours, Tina had received a new liver.
For care managers, big wins, like getting a patient a seat in a dialysis center or discharging someone who has been in the hospital for more than 100 days, can power them through the disappointments. Working in tight-knit teams of three, alongside a social worker and discharge planner, can also help lighten the daily load that comes with navigating through the barriers—homelessness, tenuous housing, financial lack—that their patients face.
And the challenges that care managers take on, and their wins, can be a sigh of relief for doctors. “Sometimes, it feels like there’s case management magic,” says Dr. Banks. “Whenever I ask them for something, they always say, ‘We’ll try!’”
Says Mayra, “I had a patient recently who’d had surgery. Her kids were there, and you could just see the pain and worry in their eyes. That’s what makes me want to keep going to work—I know the patient has a family, and that family is concerned. I have to make sure each patient gets what they need.”
Says Ann, “Once a patient hears what a case manager does, you can see their shoulders relax. This puff comes out of them. They relax because it takes a huge burden off them.”
The patients, their families, and their stories are what keep the care managers going to make calls, find creative solutions, and stay persistent.
“Without care managers,” says Dr. Banks, “the work would only be half done.”
*pseudonym used